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Epinephrine Shortage Worries Doctors During Allergy Season

June 21, 2010
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My oldest son always carries an EPI-pen (short for Epinephrine), as I have to give him three shots for his severe allergies to just about everything "green." It is a life-saving drug that is used for cardiac arrest, allergic reaction, asthma attacks and emphysema patients. Early this month, the U.S. Food and Drug Administration put Epinephrine on its list of drug shortages. The time of year couldn’t be worse – the sudden heat increases cases of difficulty breathing, cardiac arrest and even insect bites. Hospira is currently the only manufacturer of the drug. It is struggling to meet demand after another company stopped making it late last year. Apparently professionals have started a back-up plan that involves mixing a vial of Epinephrine that is a higher concentration with a bag of saline. The problem? The shelf life of a bag of saline is 30 days versus the boxed drug that lasts 2 years. Medical personnel are extremely worried about drug errors, just as they were when there was a heparin shortage. This will require new training and additional monitoring.

A National Alert for Serious Medication Errors (NAN) was issued on June 17, 2010 by the American Society of Health-System Pharmacists (ASHP) and the Institute for Safe Medication Practices (ISMP), warning health care practitioners about dangerous medication errors that could be caused by a shortage of Epinephrine pre-filled syringes.

The alert was prepared as a caution to health care organizations and practitioners, even though there had been no reports of deaths or serious errors at that time. However, days before the alert was finalized, news media in Bangor, Maine, reported the death of a hospital patient from an overdose of Epinephrine. It is unknown at this time whether the Epinephrine shortage was a factor in the deadly error. The NAN warns health care practitioners about dangers posed by this drug shortage, and includes recommendations to prevent medication errors that could result from the shortage. The NAN was developed by the American Society of Health-System Pharmacists and the Institute for Safe Medication Practices to help bring an end to deadly medication errors. Physicians, pharmacists and nurses are expected to use the recommendations to take immediate action to prevent serious medication errors at their facility.

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Specific recommendations include the following:

EPINEPHrine should be spelled with some Tall Man Letters to help prevent medication errors caused by lookalike drug names.

Pharmacists should assess all areas where EPINEPHrine emergency syringes potentially may be used, including area emergency services and response teams, and they should educate clinicians regarding the shortage and recommend substitute products.

Current supplies of EPINEPHrine emergency syringes should be conserved for code boxes and emergency responders (i.e., for code situations in which pharmacists would not be present to dilute EPINEPHrine). Pharmacists should also consider whether the number of syringes can be reduced to 2 per crash cart.

Multiple-dose 30-mL vials of injectible EPINEPHrine 1 mg/mL should not be stocked in code boxes because they closely resemble the 30-mL vials of topical EPINEPHrine, which may also be stocked in code boxes or used in the operating room.

Intracardiac EPINEPHrine should have auxiliary labels warning against intravenous and endotracheal use and alerting practitioners to the danger of injury with attempted removal of the fixed needle. These syringes should also clearly be labeled “For Intracardiac Use Only.”

When 1 mg/1 mL ampuls or vials are used instead of emergency syringes, the vial, diluent, and syringe label should be packaged in a clear plastic bag prominently labeled with the drug name and strength. Instructions should be included for preparing a dilution equivalent to a prefilled 1 mg/10 mL emergency syringe (ie, EPINEPHrine 1 mg — dilute in 9 mL of sodium chloride 0.9%).

When ampuls or vials labeled as 1:1000 are substituted, a chart for converting doses in milligrams to milliliters should be provided, as well as instructions for preparing a dilution in code carts. These charts should be posted in areas where EPINEPHrine is often used.